Synergy - July/August 2013 - 17

industry feature

Telemedicine Entity:	Under	CMS	
regulations,	a	Telemedicine	Entity	is	one	
that:	(1)	provides	telemedicine	services;	(2)	
is	not	a	Medicare-participating	hospital;	and	
(3)	provides	contracted	services	to	a	hospital	
in	a	manner	that	enables	the	hospital	to	
meet	applicable	Medicare	Conditions	
of	Participation	(CoPs).	For	example,	an	
organization	that	provides	teleradiology	
services	may	be	a	Telemedicine	Entity.

CMS and TJC Requirements
1. CMS Regulations
CMS	regulations	permit	hospitals	to	grant	
privileges	to	telemedicine	practitioners	based	
on	the	credentialing	and	privileging	decisions	
of	a	Distant	Site	hospital	or	a	Telemedicine	
Entity.	As	CMS	stated,	smaller	hospitals	
may	be	overwhelmed	by	“the	burden	of	
privileging	hundreds	of	specialty	physicians	
and	practitioners	that	large	academic	medical	
centers	make	available	to	them.”	Similarly,	
“the	costs	involved”	and	lack	of	“clinical	
expertise	to	adequately	evaluate	and	privilege	
the	wide	range	of	specialty	physicians”	may	
make	it	difficult	for	hospitals	to	credential	
and	privilege	telemedicine	practitioners.
That	said,	hospitals	wishing	to	make	use	
of	telemedicine	practitioners	are	not	
required	to	rely	on	the	credentialing	and	
privileging	decisions	of	Distant	Site	hospitals	
or	Telemedicine	Entities.	Some	hospitals	
may	prefer	to	fully	credential	and	privilege	
telemedicine	practitioners	using	their	
standard	medical	staff	process.
If	a	hospital	does	wish	to	take	advantage	of	
the	alternative	process	permitted	by	CMS,	it	
must	enter	into	a	written	agreement	with	the	
Distant	Site	hospital	or	Telemedicine	Entity	
that	meets	the	following	requirements:
1.	Credentialing and Privileging Process.	A	
Distant	Site	hospital	must	be	a	Medicareparticipating	hospital	(and	thus	governed	
by	the	CoPs	related	to	credentialing	and	
privileging).	A	Telemedicine	Entity	must	
affirm	that	it	uses	a	credentialing	and	
privileging	process	that	satisfies	the	CoPs.
2.	List of privileges.	The	Distant	Site	hospital	
or	Telemedicine	Entity	must	agree	to	provide	
to	the	Originating	Site	hospital	a	current	list	
of	the	telemedicine	practitioner’s	privileges.			
3.	Licensing.	The	telemedicine	practitioner	
at	the	Distant	Site	hospital	or	Telemedicine	

Entity	must	hold	a	license	to	practice	
recognized	in	the	state	where	the	patient	
receiving	the	service	is	located.		

–	 Requirement	that	both	parties	have	
professional	liability	insurance	at	a	
specified	coverage	level;

4.	Information exchange.	Once	a	practitioner	
begins	to	provide	telemedicine	services,	the	
Originating	Site	hospital	must	review	his	or	
her	performance	of	those	services	and	send	
to	the	Distant	Site	hospital	or	Telemedicine	
Entity	performance	information	for	use	in	
the	periodic	appraisal	of	the	Distant	Site	
physician	or	practitioner.	This	must	include	
all	adverse	results	and	all	complaints	about	
the	Distant	Site	physician	or	practitioner.

–	 Standard	contractual	terms	and	
features,	including	(but	not	limited	to)	
effective	dates,	termination	dates	and	
provisions,	appropriate	signatures	and	
dispute	resolution	methods;	and	

Importantly,	the	board	of	directors	of	the	
Originating	Site	must	actually	grant	clinical	
privileges	to	telemedicine	practitioners.	

–	 A	provision	describing	the	Originating	
Site’s	access	to	the	credentials	file	of	
the	telemedicine	practitioner.	As	CMS	
has	stated:	“We	would	expect	the	
parties	engaged	in	the	agreement	to	
determine,	within	the	written	details	of	
the	agreement	or	contract,	how	much	
information	would	need	to	be	included	

Importantly, the board of directors of the
Originating Site must actually grant clinical
privileges to telemedicine practitioners.
While	the	board	can	rely	on	the	decisions	
of	the	Distant	Site	hospital	or	Telemedicine	
Entity,	it	still	must	take	the	affirmative	step	
of	granting	privileges.	The	written	agreement	
should	make	clear	that	a	telemedicine	
practitioner	will	not	provide	any	services	
until	clinical	privileges	have	been	granted	by	
the	Originating	Site	hospital.
5.	Additional provisions.	While	not	required	
by	CMS,	written	agreements	between	
Originating	Site	hospitals	and	Distant	Site	
hospitals	or	Telemedicine	Entities	should	
also	include:
–	 Provisions	to	ensure	ongoing	protection	
of	peer	review	findings	and	other	
confidential	information;	
–	 An	indemnification	provision.	The	
written	agreement	itself	may	not	
insulate	an	Originating	Site	hospital	
and	its	medical	staff	from	a	negligent	
credentialing	claim	if	the	Distant	Site	
facility	does	not	actually	comply	with	
Medicare	credentialing	standards.	
Therefore,	the	agreement	should	include	
a	provision	stating	that	the	Distant	Site	
facility	will	indemnify	the	Originating	
Site	for	any	liability	caused	by	the	
Distant	Site’s	failure	to	comply	with	its	
obligations	under	the	agreement;	

and	sent	for	each	practitioner	providing	
telemedicine	services	to	the	hospital	
or	CAH.	At	the	very	least,	as	part	of	
its	agreement	with	the	Distant	Site	
hospital,	we	would	expect	a	hospital	
or	CAH	to	have	access	to	the	complete	
credentialing	and	privileging	file	upon	
request	for	each	practitioner	who	is	
covered	by	the	agreement.”
Note that the Originating Site hospital
still must query the National Practitioner
Data Bank.

2. Joint Commission Standards
In	addition	to	complying	with	the	CMS	
requirements	set	forth	above,	hospitals	that	
are	accredited	by	The	Joint	Commission	
must	satisfy	a	few	additional	requirements.	
Most	importantly,	if	the	telemedicine	
practitioner	will	have	either	total	or	shared	
responsibility	for	the	patient	(e.g.,	able	to	
write	orders),	then	the	Distant	Site	hospital	
or	Telemedicine	Entity	whose	credentialing	
and	privileging	decisions	are	being	relied	
upon	must	be	accredited	by	The	Joint	
Commission.	In	addition,	the	medical	staff	at	
the	Originating	Site	hospital	is	expected	to	
recommend	the	clinical	services	that	can	be	
provided	via	telemedicine.
July/A ugust 2013 SYNERGY

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Synergy - July/August 2013

Table of Contents for the Digital Edition of Synergy - July/August 2013
